A nurse in the emergency department is caring for a 52-year-old male client experiencing chest pain. Below are the exhibits to guide your answer:
Complete the diagram by dragging from the choices below to specify:
- The condition the client is most likely experiencing.
- Two actions the nurse should take.
- Two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition: Myocardial infarction.
2 actions:
Administer oxygen via nasal cannula 2 L/min,
Request a prescription for aspirin 325 mg.
2 parameters:
Vital signs,
Electrocardiogram (ECG) rhythm.
Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.
Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.
Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Checking the blood pressure is not the priority action in this case. The symptoms described may suggest compartment syndrome, which is a medical emergency and requires immediate intervention.
Choice B rationale
The correct action is to notify the health care provider immediately as this may indicate compartment syndrome, a serious complication that can occur after fractures and can lead to permanent damage if not treated promptly.
Choice C rationale
Assessing the incision for redness is not appropriate in this scenario as the symptoms suggest a more severe underlying issue such as compartment syndrome, which requires urgent attention.
Choice D rationale
Repositioning the leg may provide temporary relief but does not address the potential underlying issue of compartment syndrome. The priority is to notify the health care provider.
Correct Answer is A
Explanation
Choice A rationale
Continuing to monitor the client's respiratory status is the appropriate action if fluctuation is observed in the suction control chamber. Fluctuations are expected and indicate that the system is functioning correctly.
Choice B rationale
Checking the suction control outlet on the wall is necessary if there are signs that the system is not functioning correctly, but fluctuation itself is not an indication of malfunction.
Choice C rationale
Checking the tubing connections for leaks is important if there is an air leak suspected. However, normal fluctuation does not suggest a leak.
Choice D rationale
Clamping the chest tube is generally avoided unless absolutely necessary as it can lead to the accumulation of air and tension pneumothorax.
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